Bariatric Surgery News

The weight-loss (bariatric) surgeons are on the prowl, looking for new candidates for surgery. Now it seems they have some more evidence to back up their claims. New studies report that “mildly obese” people (BMI 30–34.9) gain as much benefit from surgery — in terms of weight, blood glucose, blood pressure, and cholesterol control — as heavier people do.

I apologize if this is starting to sound more like a weight blog than a diabetes blog. But these are important questions and this is interesting science. Last week I reported on studies showing that overweight people (BMI 25–29.9) lived longer than normal weight people. What does this new report mean for us?

Choi reported on five studies showing great benefit for people with BMIs under 35 who received surgery. (Note: For a 5′ 10″ person, a BMI of 30 is a weight of roughly 210 pounds, a BMI of 35 is about 245 pounds, and a BMI of 40 is approximately 280 pounds. I used this BMI calculator to determine these numbers.) The largest of the studies involved 210 people with BMIs under 35 who were treated with gastric banding and followed for five years. Loss of excess weight averaged 71% for these people. More importantly, 89% of the people saw an improvement or complete resolution of conditions such as Type 2 diabetes, hypertension, sleep apnea, as well as other conditions including arthritis, asthma, and depression. Six percent of people had “significant” complications of the surgery, including two cases of the gastric band slipping and one of the band eroding, but none of the complications were fatal.

What does it Mean?
Currently, the National Institutes of Health (NIH) guidelines approve bariatric surgery for people with BMI over 40 or a BMI over 35 and significant “comorbidities.” “Comorbidities” basically means “other conditions.” The ones usually mentioned with obesity are diabetes, high cholesterol, and high blood pressure.

Choi and colleagues suggest the guidelines be lowered to a BMI of less than 35 without comorbidities or a BMI of less than 30 with comorbidities. In Italy and India, they’re doing surgery for people with even lower BMIs. In an Indian study, Shashank Shah, MD, reported on 15 people who had a BMI of 22 to 35. All had poorly controlled Type 2 diabetes. Most also had hypertension and cholesterol problems. Most of them had improved BMIs, blood pressure, and cholesterol at nine months follow-up. The article I read did not mention surgical complications in this group.

The surgeons want the guidelines changed so they can get paid for doing more surgeries, which means we should be skeptical of their claims. However, this evidence does look pretty strong.

Surgery might be appropriate for people who are having metabolic symptoms. If you have elevated A1C, cholesterol, or blood pressure, or if weight is contributing to arthritis, sleep apnea, or gastric reflux (GERD), banding might be an option, even if your BMI is below 40.

On the other hand, if your metabolic numbers and general health are good, you might want to leave the weight alone. You’re probably all right with it, as long as you stay in shape and your numbers are OK. Unfortunately, that situation doesn’t apply to many people with diabetes.

But Does it Last?
It’s important to note that both the weight loss and metabolic improvements from surgery may not last. Long-term follow up of people who have had gastric bypass show significant regain of weight, and often of cholesterol, as well as fasting glucose level over five or more years. There are also dangerous side effects of some surgeries, although for gastric banding, the incidence is low. Banding and some gastric bypasses can now be done by laparoscope (a method of minimally invasive surgery in which only small incisions are made), so it’s much easier to heal from.

Other studies show additional advantages of surgery. A recent report from Utah found a lower cancer risk and a roughly 40% reduction in cancer deaths in people who’d had bariatric surgery, compared to obese people in a control group.

As you can probably tell, I’m conflicted about this. I hate the notion that we have to mutilate our bodies to be “healthy.” It kind of twists the idea of what health even means. But it seems to me that the environment is sick, with too much bad food and stress, and so many obstacles to physical activity. The bodies we are born with may not be good matches for our environment any more.

What do you think? Let me know, and I’ll stop discussing weight for a while.

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Steve Parker, M.D.

Before I’d consider bariatric surgery for a BMI of 30-35, I’d be sure I exhausted all other reasonable options for weight management. It’s just too risky.

-Steve
-http://diabeticmediterraneandiet.com

CalgaryDiabetic

Dear David.

I have just spent a few days in copenhagen and stockholm. There were two things that were remarquable. The fraction of people that were overweight and obese were very noticeably smaller than in America.

Another thing was the real estate was in very good repair. No urban or rural decay and we took the train from Copenhagen to Stockholm. Usually buildings close to trains are in the worst shape and no rot and decay at all.

Makes you wonder why this lack of obesity? Could be mostly genetics. Social systems in these counties are a total opposite of America. It is much harder for the peasant class to become a millionaire than it is in america but if life’s luck goes against you there is a very good social net compared to Canada where you will end up on the street. In minus 20 this is not fun. You wonder if this reduced stress could be a factor?

Also food is much more expensive there the more so in Copenhagen. We I visited the USA last in 2003. I was shocked to find the junk food half price compared to Canada but the “good ” food in the supermarket much more expensive.

Pam

Maybe if these same people stuck to healthy eating and exercise they would lose weight and have the same health benefits. They would not be contributing to increased insurance premiums for us all, would not be killing us taxpayers with increase costs to fund medicaid, medicare and disability. Yes surgeons are getting rich at the taxpayers expense. How about the overweight taking responsibility for their own weight gain and health outcomes.

David Spero RN

Hi Pam,

Thanks for your comment. Unfortunately, it shows great ignorance about both the causes and costs of fatness. The causes, as Calgary Diabetic suggested in the comment before yours, are mostly social, and the costs are greatly overstated. See this article: http://usgovinfo.about.com/od/healthcare/a/cdcbadstats.htm.

You can also read Chapters 1–3 of my book Diabetes: Sugar-Coated Crisis to learn about the social causes of illness. Read Chapter 1 for free at http://www.davidsperorn.com.

Gloria

I understand why you are conflicted David. I feel the same way. I ruined my metabolism by struggling to change my curvy (I’m a woman) to a much desired skinny body for years! Doctors telling me to lose weight,& finding that eating sensibly & exercising only served to build muscle and ADD weight to my frame, I was given diet pills, told to eat no more than 700 calories a day, & in striving to please everybody, & prove I could win the battle, I even became bullemic with anorexic tendancies. I never did become thin. Not by other people’s standards anyway. Now I am diabetic, and have requested surgery, but so far nobody wants to endorse it. I don’t lose weight unless I take drastic, unnatural, & unhealthy measures anyway, so why not surgery? My present physicians tell me now that my weight is mostly a matter of heredity. If it was not for the type 2 diabeties, I wouldn’t even consider getting cut on!

Johanne

David, I have read your report and would love to comment. I would love to be able to have The “BAND”,but I have a laundry list of illnesses that would most probably disappear if done….BUT I’m told I’m to old, (70). It would certainly change my life. My neice is 5 months out and she is doing fantastic.
I would tell anyone who can do it,
go for it !!!
JS

Guen Outwater

I had gastric by-pass almost 4 yrs. ago and I am convinced that it saved my life. I was so emotionally bankrupt that I was killing myself with every mouthfull. I am a insulin pump user and although I still have my pump(pancreas is not working for the most part)I am very much more under control. I, also, realize that this step is not for everyone, but for me it has been wonderful. You also have to be emotionally ready and willing to do what your doctors tell you to. This surgery is not a cure, it is only a tool. You still have to exercise and eat healthily.

Guen O.

Michigan

Mary Jenkins

I am 55 years old and 70 pounds over weight. I have been a type 2 Diabetic for the past 5 years. My doctor has suggested that I start using a insulin pump. I have also thought that maybe gastric by-pass or band would also be an option. My doctor won’t approve it because he said that I wasn’t over weight enough.

I have been on insulin for the pass 6 months. And my mother and grandmother both had diabeties. I don’t want to go through the surgery if it would not cure me. I am getting alot of different advice. I really don’t know what would be best for me.

E. Crump

I agree with Guen O. The surgery is a tool. In my opinion bariatric surgery, for some people, is the jump start they need to start living healthier lives. There are many websites like Clarian health indianapolis indiana that provide pre and post-surgery support as well as exercises, recipes, and much more.

Jennifer McFarland

Hi David,

Regarding the claim that “long-term follow up of people who have had gastric bypass show significant regain of weight, and often of cholesterol, as well as fasting glucose level over five or more years”, I am curious as to how many people and how representative the sample is that was studied here. I had gastric bypass four years ago. It’s true that I’ve gained some weight back, but only ten pounds. And that is after losing one hundred and ten pounds, still leaving me with a net loss of one hundred pounds.

I have seen instances of what you’re referring to. But I’ve seen more long term successes than failures in bariatric support groups. That brings me to another point, and it’s an important one. The bariatric support groups may or may not be representative of the whole. People in support groups have power in information, connectedness, shared hopes and struggles. I really respect your work on the social causes of type two diabetes and I’ve read your book.

I’m guessing that the same environmental factors are at play in morbid obesity and that building social safety nets and creating environmental change and empowerment makes a difference in the success of the surgery. It is only a tool, not a cure. It means we have to keep working at it every day, which requires a heightened overall feeling of empowerment and hope. I’ve been blogging about it at: bariatricathletes.ning.com. Thank you for all that you do in the service of others. It really is an inspiration.

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